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Treatment of basal cell carcinomas at high risk for recurrence

Sumaira Z Aasi, MD
Section Editors
June K Robinson, MD
Robert S Stern, MD
Deputy Editor
Rosamaria Corona, MD, DSc


Basal cell carcinoma (BCC) is a common skin cancer that arises from the basal layer of epidermis and its appendages. Treatment of BCC is indicated due to the locally invasive, aggressive, and destructive effects of BCC on skin and surrounding tissues (picture 1A-B).

Tumor characteristics such as size, location, and pathology influence the likelihood for deep tumor invasion and recurrence of BCC after treatment. Lesions at high risk for recurrence may benefit from removal with Mohs micrographic surgery, a procedure that allows for the assessment of all margins of excised tissue. Alternative therapies include conventional surgical excision and radiation therapy (RT). Electrodessication and curettage (ED&C), cryosurgery, and topical 5-fluorouracil or imiquimod are not recommended for the management of these BCCs (table 1).

The treatment of BCCs with clinical or pathologic features associated with increased risk for recurrence will be reviewed here. The risk factors, clinical manifestations, and prognosis of BCC, as well as the management of less aggressive BCCs, are reviewed separately. The management of advanced BCC is also discussed separately.

(See "Epidemiology, pathogenesis, and clinical features of basal cell carcinoma".)

(See "Treatment and prognosis of basal cell carcinoma at low risk of recurrence".)

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Literature review current through: Nov 2017. | This topic last updated: Dec 12, 2017.
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  1. Batra RS, Kelley LC. Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with Mohs micrographic surgery. Arch Dermatol 2002; 138:1043.
  2. Walling HW, Fosko SW, Geraminejad PA, et al. Aggressive basal cell carcinoma: presentation, pathogenesis, and management. Cancer Metastasis Rev 2004; 23:389.
  3. Miller SJ, Alam M, Andersen J, et al. Basal cell and squamous cell skin cancers. J Natl Compr Canc Netw 2010; 8:836.
  4. Mehrany K, Weenig RH, Pittelkow MR, et al. High recurrence rates of Basal cell carcinoma after mohs surgery in patients with chronic lymphocytic leukemia. Arch Dermatol 2004; 140:985.
  5. Brown CI, Perry AE. Incidence of perineural invasion in histologically aggressive types of basal cell carcinoma. Am J Dermatopathol 2000; 22:123.
  6. Leibovitch I, Huilgol SC, Selva D, et al. Basal cell carcinoma treated with Mohs surgery in Australia III. Perineural invasion. J Am Acad Dermatol 2005; 53:458.
  7. Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989; 15:424.
  8. Leibovitch I, Huilgol SC, Selva D, et al. Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up. J Am Acad Dermatol 2005; 53:452.
  9. Smeets NW, Krekels GA, Ostertag JU, et al. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004; 364:1766.
  10. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs' micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years' follow-up. Lancet Oncol 2008; 9:1149.
  11. Salasche SJ. Curettage and electrodesiccation in the treatment of midfacial basal cell epithelioma. J Am Acad Dermatol 1983; 8:496.
  12. Suhge d'Aubermont PC, Bennett RG. Failure of curettage and electrodesiccation for removal of basal cell carcinoma. Arch Dermatol 1984; 120:1456.
  13. Silverman MK, Kopf AW, Grin CM, et al. Recurrence rates of treated basal cell carcinomas. Part 2: Curettage-electrodesiccation. J Dermatol Surg Oncol 1991; 17:720.
  14. Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: tissue-sparing outcome. Dermatol Surg 2009; 35:1349.
  15. Drake LA, Dinehart SM, Goltz RW, et al. Guidelines of care for Mohs micrographic surgery. American Academy of Dermatology. J Am Acad Dermatol 1995; 33:271.
  16. van Loo E, Mosterd K, Krekels GA, et al. Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up. Eur J Cancer 2014; 50:3011.
  17. Boulinguez S, Grison-Tabone C, Lamant L, et al. Histological evolution of recurrent basal cell carcinoma and therapeutic implications for incompletely excised lesions. Br J Dermatol 2004; 151:623.
  18. Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol 2012; 67:531.
  19. Chren MM. Determining the value of surgical therapies for basal cell carcinoma. Arch Dermatol 2006; 142:231.
  20. Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis. J Am Acad Dermatol 1998; 39:698.
  21. Essers BA, Dirksen CD, Nieman FH, et al. Cost-effectiveness of Mohs Micrographic Surgery vs Surgical Excision for Basal Cell Carcinoma of the Face. Arch Dermatol 2006; 142:187.
  22. Dubin N, Kopf AW. Multivariate risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 1983; 119:373.
  23. Silverman MK, Kopf AW, Bart RS, et al. Recurrence rates of treated basal cell carcinomas. Part 3: Surgical excision. J Dermatol Surg Oncol 1992; 18:471.
  24. Wolf DJ, Zitelli JA. Surgical margins for basal cell carcinoma. Arch Dermatol 1987; 123:340.
  25. Bart RS, Schrager D, Kopf AW, et al. Scalpel excision of basal cell carcinomas. Arch Dermatol 1978; 114:739.
  26. Lawrence CM, Haniffa M, Dahl MG. Formalin-fixed tissue Mohs surgery (slow Mohs) for basal cell carcinoma: 5-year follow-up data. Br J Dermatol 2009; 160:573.
  27. Morris DS, Elzaridi E, Clarke L, et al. Periocular basal cell carcinoma: 5-year outcome following Slow Mohs surgery with formalin-fixed paraffin-embedded sections and delayed closure. Br J Ophthalmol 2009; 93:474.
  28. Lovett RD, Perez CA, Shapiro SJ, Garcia DM. External irradiation of epithelial skin cancer. Int J Radiat Oncol Biol Phys 1990; 19:235.
  29. Petit JY, Avril MF, Margulis A, et al. Evaluation of cosmetic results of a randomized trial comparing surgery and radiotherapy in the treatment of basal cell carcinoma of the face. Plast Reconstr Surg 2000; 105:2544.
  30. Avril MF, Auperin A, Margulis A, et al. Basal cell carcinoma of the face: surgery or radiotherapy? Results of a randomized study. Br J Cancer 1997; 76:100.
  31. Silverman MK, Kopf AW, Gladstein AH, et al. Recurrence rates of treated basal cell carcinomas. Part 4: X-ray therapy. J Dermatol Surg Oncol 1992; 18:549.
  32. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989; 15:315.
  33. Locke J, Karimpour S, Young G, et al. Radiotherapy for epithelial skin cancer. Int J Radiat Oncol Biol Phys 2001; 51:748.
  34. Wilder RB, Shimm DS, Kittelson JM, et al. Recurrent basal cell carcinoma treated with radiation therapy. Arch Dermatol 1991; 127:1668.
  35. Fleming ID, Amonette R, Monaghan T, Fleming MD. Principles of management of basal and squamous cell carcinoma of the skin. Cancer 1995; 75:699.
  36. Kwan W, Wilson D, Moravan V. Radiotherapy for locally advanced basal cell and squamous cell carcinomas of the skin. Int J Radiat Oncol Biol Phys 2004; 60:406.
  37. Caccialanza M, Piccinno R, Beretta M, Gnecchi L. Results and side effects of dermatologic radiotherapy: a retrospective study of irradiated cutaneous epithelial neoplasms. J Am Acad Dermatol 1999; 41:589.
  38. Griep C, Davelaar J, Scholten AN, et al. Electron beam therapy is not inferior to superficial x-ray therapy in the treatment of skin carcinoma. Int J Radiat Oncol Biol Phys 1995; 32:1347.
  39. Petrovich Z, Kuisk H, Langholz B, et al. Treatment of carcinoma of the skin with bone and/or cartilage involvement. Am J Clin Oncol 1988; 11:110.
  40. Lichter MD, Karagas MR, Mott LA, et al. Therapeutic ionizing radiation and the incidence of basal cell carcinoma and squamous cell carcinoma. The New Hampshire Skin Cancer Study Group. Arch Dermatol 2000; 136:1007.
  41. Karagas MR, McDonald JA, Greenberg ER, et al. Risk of basal cell and squamous cell skin cancers after ionizing radiation therapy. For The Skin Cancer Prevention Study Group. J Natl Cancer Inst 1996; 88:1848.
  42. Goldschmidt H, Breneman JC, Breneman DL. Ionizing radiation therapy in dermatology. J Am Acad Dermatol 1994; 30:157.
  43. Malkinson FD. Radiobiology of the skin. In: Fitzpatrick's Dermatology in General Medicine, 5th ed, Freedberg IM, et al (Eds), McGraw-Hill, New York 1999. Vol 1, p.1514.
  44. Chao CK, Gerber RM, Perez CA. Reirradiation of recurrent skin cancer of the face. A successful salvage modality. Cancer 1995; 75:2351.
  45. Vinciullo C, Elliott T, Francis D, et al. Photodynamic therapy with topical methyl aminolaevulinate for 'difficult-to-treat' basal cell carcinoma. Br J Dermatol 2005; 152:765.
  46. Horn M, Wolf P, Wulf HC, et al. Topical methyl aminolaevulinate photodynamic therapy in patients with basal cell carcinoma prone to complications and poor cosmetic outcome with conventional treatment. Br J Dermatol 2003; 149:1242.
  47. Love WE, Bernhard JD, Bordeaux JS. Topical imiquimod or fluorouracil therapy for basal and squamous cell carcinoma: a systematic review. Arch Dermatol 2009; 145:1431.
  48. Farhadi M, Kamrava SK, Behzadi AH, et al. The efficacy of photodynamic therapy in treatment of recurrent squamous cell and basal cell carcinoma. J Drugs Dermatol 2010; 9:122.
  49. Garcia-Martin E, Gil-Arribas LM, Idoipe M, et al. Comparison of imiquimod 5% cream versus radiotherapy as treatment for eyelid basal cell carcinoma. Br J Ophthalmol 2011; 95:1393.
  50. Carneiro RC, de Macedo EM, Matayoshi S. Imiquimod 5% cream for the treatment of periocular Basal cell carcinoma. Ophthal Plast Reconstr Surg 2010; 26:100.
  51. Blasi MA, Giammaria D, Balestrazzi E. Immunotherapy with imiquimod 5% cream for eyelid nodular basal cell carcinoma. Am J Ophthalmol 2005; 140:1136.
  52. Amini S, Viera MH, Valins W, Berman B. Nonsurgical innovations in the treatment of nonmelanoma skin cancer. J Clin Aesthet Dermatol 2010; 3:20.
  53. Leppälä J, Kaarniranta K, Uusitalo H, Kontkanen M. Imiquimod in the treatment of eyelid basal cell carcinoma. Acta Ophthalmol Scand 2007; 85:566.
  54. Choontanom R, Thanos S, Busse H, Stupp T. Treatment of basal cell carcinoma of the eyelids with 5% topical imiquimod: a 3-year follow-up study. Graefes Arch Clin Exp Ophthalmol 2007; 245:1217.
  55. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/203388lbl.pdf (Accessed on January 31, 2012).
  56. Moeholt K, Aagaard H, Pfeiffer P, Hansen O. Platinum-based cytotoxic therapy in basal cell carcinoma--a review of the literature. Acta Oncol 1996; 35:677.
  57. Caron J, Dereure O, Kerob D, et al. Metastatic basal cell carcinoma: report of two cases treated with cetuximab. Br J Dermatol 2009; 161:702.